The present invention generally relates to building and maintaining medical vocabularies. In particular, the present invention relates to systems, methods, and apparatus for supplementing a controlled medical vocabulary with localized clinical content.
Medical text plays an important role in the delivery of healthcare. Using medical text, medical concepts and information can be exchanged using a variety of documents including progress notes, discharge summaries, prescriptions, procedure reports, etc. Medical terminology is voluminous, fragmented, and complex. Multiple standards bodies (e.g., Health Level Seven (HL7), World Health Organization (WHO), etc.) make contributions to categorizing and publishing medical vocabularies (e.g. Systematized Nomenclature of Human and Veterinary Medicine (SNOMED), International Classification of Diseases (ICD), Logical Observation Identifier Names and Codes (LOINC), etc.) across multiple healthcare domains (e.g., medical procedures, problem lists, laboratory, etc.). In developing clinical information systems, data collection can be driven via a controlled medical vocabulary (CMV) that spans multiple organizations and source terminologies. The CMV can be continuously updated and is able to grow and evolve with the growing list of codes and terms.
In many cases, mapping between terminologies has been accomplished for common terminologies that have overlapping information domains. These mappings are made available by government agencies, healthcare providers, and third party content providers. Most approaches to managing a CMV rely on mapping rules and use of human intervention of terminology engineers or medical coders to understand differences across source vocabularies, to rationalize the organization of data (via hierarchies and relationships), to identify differences in granularity, and to map between codes and synonyms where there is overlap. This process requires a large amount of manpower to maintain an updated vocabulary and is especially burdensome when implementing new systems in an established healthcare organization with an abundance of systems and proprietary codes and synonyms. Combined with internationalization and a desire to share data across healthcare organizations, the problem quickly becomes unmanageable. For this reason, many healthcare IT providers have created their own proprietary codes, relationships, terms, and picklists which remain unintegrated with our systems and terminologies.